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2.
Acute Crit Care ; 39(2): 282-293, 2024 May.
Artículo en Inglés | MEDLINE | ID: mdl-38863359

RESUMEN

BACKGROUND: This study evaluates the effectiveness of Therapeutic Hypothermia (TH) in treating poor-grade aneurysmal subarachnoid hemorrhage (SAH), focusing on functional outcomes, mortality, and complications such as vasospasm, delayed cerebral ischemia (DCI), and hydrocephalus. METHODS: Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines, a comprehensive literature search was conducted across multiple databases, including Medline, Embase, and Cochrane Central, up to November 2023. Nine studies involving 368 patients were selected based on eligibility criteria focusing on TH in poor-grade SAH patients. Data extraction, bias assessment, and evidence certainty were systematically performed. RESULTS: The primary analysis of unfavorable outcomes in 271 participants showed no significant difference between the TH and standard care groups (risk ratio [RR], 0.87). However, a significant reduction in vasospasm was observed in the TH group (RR, 0.63) among 174 participants. No significant differences were found in DCI, hydrocephalus, and mortality rates in the respective participant groups. CONCLUSIONS: TH did not significantly improve primary unfavorable outcomes in poor-grade SAH patients. However, the reduction in vasospasm rates indicates potential specific benefits. The absence of significant findings in other secondary outcomes and mortality highlights the need for further research to better understand TH's role in treating this patient population.

3.
J Neurointerv Surg ; 2024 Mar 15.
Artículo en Inglés | MEDLINE | ID: mdl-38490734

RESUMEN

OBJECTIVE: To analyze the relationship between in-stent restenosis (ISR) following carotid artery stenting (CAS) and platelet clopidogrel reactivity confirmed by the P2Y12 reaction unit (PRU) and inhibition rate (IR). METHODS: We retrospectively analyzed 171 patients who underwent CAS with extracranial carotid stenosis from January 2016 to December 2019. Dual antiplatelet therapy with 100 mg aspirin and 75 mg clopidogrel was started ≥5 days before CAS. Clopidogrel resistance was measured with the PRU and IR the day before CAS. The ISR degree was classified into R1, R2, and R3 (moderate to severe luminal stenosis of ≥50% or occlusion) by carotid CT angiography after 24-30 months. The degree of quantitative association between platelet reactivity and ISR R3 was determined by the receiver operating characteristic curve method. The optimal cut-off values of PRU and IR were derived using the maximum Youden index. RESULTS: There were 33 R3 degrees of ISR (19.3%) and nine ipsilateral ischemic strokes (5.3%). The PRU and IR were different between R1+R2 degrees (176.4±50.1, 27.5±18.7%) and R3 degree (247.5±55.0, 10.3±13.4%) (P<0.001). The areas under the curves of PRU and IR were 0.841 and 0.781, and the optimal cut-off values were 220.0 and 14.5%, respectively. Multivariate logistic regression analysis showed that PRU ≥220 and IR ≤14.5% were significant predictive factors for ISR R3 (P<0.001 and P=0.017, respectively). ISR R3 was independently associated with ipsilateral ischemic stroke after CAS (P=0.012). CONCLUSIONS: High PRU (≥220) and low IR (≤14.5%) are related to ISR R3 following CAS, which may cause ipsilateral ischemic stroke.

4.
World Neurosurg ; 2023 Dec 23.
Artículo en Inglés | MEDLINE | ID: mdl-38143037

RESUMEN

BACKGROUND: We sought to determine the utility of intracranial-to-intracranial bypass (IIB) surgery and the available bypass options for complex cases. METHODS: A total of 18 IIB cases were included. Each case was classified as IIB with or without an interposition graft. The clinical and angiographic status were evaluated pre- and postoperatively and at the last follow-up. Angiographic images were analyzed and reconstructed schematically. Postoperative angiography was used to measure the bypass patency and the presence of postoperative cerebral infarction. The recipient artery occlusion time for each bypass was measured. RESULTS: Of the 18 patients, 14 had presented with a complex intracranial aneurysm (IA), 1 with vertebrobasilar dolichoectasia, and 3 with intracranial arterial steno-occlusive disease. Ten patients had an incidentally discovered IA. Seven patients had presented with neurological deficits due to ischemia or aneurysmal mass effects. Of the 18 cases, 10 were IIBs with an interposition graft, including 4 cases of superficial temporal artery and 6 of radial artery graft bypass, and 8 were IIBs with a noninterposition graft, including 3 cases of in situ bypass, 1 case of reanastomosis, and 4 cases of reimplantation. The pre- and postoperative modified Rankin scale score did not change or improve, and all the bypasses were patent. No patient had died during the mean follow-up period of 50.0 months. The mean occlusion time of the recipient artery was 59.5 minutes. A total of 8 patients experienced postoperative cerebral infarction but all had almost recovered at discharge. CONCLUSIONS: With proper selection of the IIB type, IIB can be a suitable treatment option for some patients with complex IAs and intracranial arterial steno-occlusive disease when extracranial-to-intracranial bypass is not feasible.

5.
J Cerebrovasc Endovasc Neurosurg ; 25(4): 390-402, 2023 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-37583078

RESUMEN

OBJECTIVE: Chronic subdural hematoma (CSDH) is a neurological complication following clipping surgery. However, the natural course and ideal approach for the treatment of clipping-related-CSDH (CR-CSDH) have not been clearly established. We aimed to investigate the course of CR-CSDH using chronological radiological findings. METHODS: We performed a retrospective analysis of 28 (3.8%) patients who developed CSDH among 736 patients who underwent surgical clipping using pterional approach for unruptured aneurysms at our institution between December 2010 and December 2018. Patients underwent follow-up CT scan 6-8 weeks after clipping surgery and decision to pursue surgical intervention rests upon the patient's symptom based on the Markwalder's grading scale (MGS) and numeric rating scale (NRS). RESULTS: Of the 28 patients, 3 patients (10.7%) underwent surgery, while 25 (89.2%) showed spontaneous resolution of CR-CSDH. Eighteen patients (64.2%) had mild headache with MGS of 0-1. The mean maximum hematoma volume was 41.9±30.9 ml (5.8-135 ml), and 26 patients (92.8%) had homogeneous hematoma. The mean time to hematoma resolution was 126.7±52.9 days (46-228 days). Comparing group of CR-CSDH volume ≥43 ml or a midline shift ≥5 mm, the difference in presence of linear low-density area (p=0.002) and age (p=0.026) between the conservative and operative groups were found to be statistically significant. CONCLUSIONS: Most CR-CSDH cases spontaneously resolved within 4 months. Therefore, we suggest that close observation should be performed if patient's symptoms are mild and special radiologic findings are present, despite its relatively large volume and midline shifting.

6.
J Cerebrovasc Endovasc Neurosurg ; 25(1): 19-27, 2023 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-36259163

RESUMEN

OBJECTIVE: The purpose of this study was to determine the efficacy of a 3D-printed aneurysm simulation model (3DPM) in educating patients and improving physicians' comprehension and performance. METHODS: This prospective study involved 40 patients who were diagnosed with unruptured intracranial aneurysms (UIAs) and scheduled for surgical clipping or endovascular coiling and randomly divided into two groups (the 3DPM group and the non-3DPM group). The 3DPM was used in preoperative consultation with patients and intraoperatively referenced by surgeons. The patients, 7 neurosurgical residents, and 10 surgeons completed questionnaires (5-point Likert scale) to determine the usefulness of the 3DPM. RESULTS: Patients in the 3DPM group had significantly higher scores in terms of their understanding of the disease (mean 4.85 vs. 3.95, p<0.001) and the treatment plan (mean 4.85 vs. 4.20, p=0.005) and reported higher satisfaction during consultation (5.0 vs. 4.60, p=0.036) than patients in the non-3DPM group. During patient consultation, 3DPMs were most useful in improving doctor-patient communication (mean 4.57, range 4-5). During clipping surgery, the models were most useful in assessing adjacent arteries (mean 4.9, range 4-5); during endovascular coiling, they were especially helpful in microcatheter shaping (mean 4.7, range 4-5). CONCLUSIONS: In general, 3DPMs are beneficial in educating patients and improving the physician's performance in terms of surgical clipping and endovascular coiling of UIAs.

7.
J Neurosurg ; 138(3): 683-692, 2023 03 01.
Artículo en Inglés | MEDLINE | ID: mdl-35901742

RESUMEN

OBJECTIVE: The aim of this study was to identify predictive factors for hemorrhagic cerebral hyperperfusion syndrome (hCHS) after direct bypass surgery in adult nonhemorrhagic moyamoya disease (non-hMMD) using quantitative parameters on rapid processing of perfusion and diffusion (RAPID) perfusion CT software. METHODS: A total of 277 hemispheres in 223 patients with non-hMMD who underwent combined bypass were retrospectively reviewed. Preoperative volumes of time to maximum (Tmax) > 4 seconds and > 6 seconds were obtained from RAPID analysis of perfusion CT. These quantitative parameters, along with other clinical and angiographic factors, were statistically analyzed to determine the significant predictors for hCHS after bypass surgery. RESULTS: Intra- or postoperative hCHS occurred in 13 hemispheres (4.7%). In 7 hemispheres, subarachnoid hemorrhage occurred intraoperatively, and in 6 hemispheres, intracerebral hemorrhage was detected postoperatively. All hCHS occurred within the 4 days after bypass. Advanced age (OR 1.096, 95% CI 1.039-1.163, p = 0.001) and a large volume of Tmax > 6 seconds (OR 1.011, 95% CI 1.004-1.018, p = 0.002) were statistically significant factors in predicting the risk of hCHS after surgery. The cutoff values of patient age and volume of Tmax > 6 seconds were 43.5 years old (area under the curve [AUC] 0.761) and 80.5 ml (AUC 0.762), respectively. CONCLUSIONS: In adult patients with non-hMMD older than 43.5 years or with a large volume of Tmax > 6 seconds over 80.5 ml, more prudence is required in the decision to undergo bypass surgery and in postoperative management.


Asunto(s)
Revascularización Cerebral , Enfermedad de Moyamoya , Adulto , Humanos , Enfermedad de Moyamoya/cirugía , Estudios Retrospectivos , Complicaciones Posoperatorias , Tomografía Computarizada por Rayos X , Síndrome , Angiografía Cerebral , Circulación Cerebrovascular
8.
Korean J Neurotrauma ; 19(4): 409-421, 2023 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-38222835

RESUMEN

Objective: Odontoid fractures are treated surgically through the anterior or posterior approach. Each surgical approach has its advantages and disadvantages, so the preferred approach remains debatable. There are few meta-analyses or systemic reviews on the mechanical complications of surgical treatment for odontoid fractures. This meta-analysis aimed to compare the operation-related morbidity, including mechanical complications, and mortality of patients with odontoid fractures, treated via the anterior or posterior approach. Methods: A systematic search was performed on PubMed/Medline, Embase, and the Cochrane Library for the studies up to October 2023 on the complication rate of the surgical treatment of odontoid fractures, related to the surgical approach. The risk ratios (RR) with the 95% confidence intervals (CIs) were pooled to assess the mechanical complication rates, other complications, revision surgery, and mortality, depending on the surgical approach. Results: A total of 1,519 studies were retrieved using the search strategy, and 782 patients from 15 articles were included in this meta-analysis. Mechanical complications were significantly more frequent in the anterior surgical group with low heterogeneity. The incidences of fracture nonunion and revision surgery were also higher in the anterior surgery group. However, there was no significant difference in systemic complications and mortality rates between the two groups. Conclusion: The posterior approach was more advantageous than the anterior approach in terms of mechanical complications, fusion rates, and incidence of revision surgery. However, further studies, should be performed to strengthen these results.

9.
J Korean Neurosurg Soc ; 65(6): 801-815, 2022 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-35728979

RESUMEN

OBJECTIVE: To evaluate the stent apposition of a low-profile visualized intraluminal support (LVIS) device in distal internal carotid artery (ICA) aneurysms, examine its correlation with clinical and angiographic outcomes, and determine the predictive factors of ischemic adverse events (IAEs) related to stent-assisted coiling. METHODS: We retrospectively analyzed a prospectively maintained database of 183 patients between January 2017 and February 2020. The carotid siphon from the cavernous ICA to the ICA terminus was divided into posterior, anterior, and superior bends. The anterior bends were categorized into angled (V) and non-angled (C, U, and S) types depending on the morphology and measured angles. Complete stent apposition (CSA) and incomplete stent apposition (ISA) were evaluated using unsubtracted angiography and flat-panel detector computed tomography. Dual antiplatelet therapy with aspirin 200 mg and clopidogrel 75 mg was administered. Clopidogrel resistance was defined as fewer responders (≥10%, <40%) and non-responders (<10%) based on the percent inhibition (%INH) of the VerifyNow system. These were counteracted by a dose escalation to 150 mg for fewer responders or substitution with cilostazol 200 mg for non-responders. IAEs included intraoperative in-stent thrombosis, transient ischemic attack, cerebral infarction, and delayed in-stent stenosis. A multivariate logistic regression analysis was used to determine the predictive factors for ISA and IAEs. RESULTS: There were 33 ISAs (18.0%) and 27 IAEs (14.8%). The anterior bend angle was narrower in ISA (-4.16°±25.18°) than in CSA (23.52°±23.13°) (p<0.001). The V- and S-types were independently correlated with the ISA (p<0.001). However, treatment outcomes, including IAEs (15.3% vs. 12.1%), aneurysmal complete occlusion (91.3% vs. 88.6%), and recanalization (none of them), did not differ between CSA and ISA (p>0.05). The %INH of 27 IAEs (13.78%±14.78%) was significantly lower than that of 156 non-IAEs (26.82%±20.23%) (p<0.001). Non-responders to clopidogrel were the only significant predictive factor for IAEs (p=0.001). CONCLUSION: The angled and tortuous anatomical peculiarity of the carotid siphon caused ISA of the LVIS device; however, it did not affect clinical and angiographic outcomes, while the non-responders to clopidogrel affected the IAEs related to stent-assisted coiling.

10.
World Neurosurg ; 166: e11-e22, 2022 10.
Artículo en Inglés | MEDLINE | ID: mdl-35569746

RESUMEN

OBJECTIVE: The objective of the study was to assess the esthetic efficacy of acellular dermal matrix (ADM) implantation to prevent frontotemporal depression (FTD) following minipterional craniotomy (MPT) to clip unruptured intracranial aneurysms. METHODS: We retrospectively compared the incidence of FTD in 100 patients treated without ADM from March to July 2019 and 100 patients treated with ADM from August to December 2019. ADM was implanted in the interfascial layer to cover the temporalis muscle. The specific location and degree of FTD were analyzed by measuring the thickness and area of multiple points (P1-P12) and regions (S1-S3) through brain computed tomography preoperatively and 1 year postoperatively. RESULTS: In the non-ADM group, the thickness at P1, P2, P5, P6, and P9 was reduced and the area of S1 and S2 was smaller after surgery than before surgery (P < 0.05), similar to the incision and suture site of the temporalis muscle. However, in the ADM group, the preoperative and postoperative measurements were not different. FTD recognition was significantly lower in the ADM group (6.0%) than that in the non-ADM group (17.0%) (P = 0.015) and occurred in the retroorbital region through P1, P2, P5, and P6, with the area under the receiver operating characteristic curves of 0.840, 0.766, 0.811, and 0.751, respectively. ADM implantation was the only significant predictive factor for FTD recognition in multivariate logistic regression analysis (odds ratio = 0.30; 95% confidence interval: 0.11-0.79; P = 0.015). CONCLUSIONS: Even MPT cannot completely prevent FTD in the retroorbital region. ADM implantation in MPT can help to improve esthetic satisfaction.


Asunto(s)
Dermis Acelular , Demencia Frontotemporal , Aneurisma Intracraneal , Craneotomía/métodos , Depresión , Demencia Frontotemporal/cirugía , Humanos , Aneurisma Intracraneal/cirugía , Estudios Retrospectivos , Instrumentos Quirúrgicos
11.
J Cerebrovasc Endovasc Neurosurg ; 24(3): 281-290, 2022 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-35570471

RESUMEN

The artery of Davidoff and Schechter (ADS), a pure meningeal branch of the posterior cerebral artery (PCA), is often reported as a feeder of the tentorial dural arteriovenous fistula (TDAVF). However, there are few reported cases of embolization via this artery. We present an interesting case of a patient with incidentally found TDAVF fed by the ADS and with fetal type posterior communicating artery, in which the feeder was confused with the PCA due to the similar pathways around the brain stem. It was successfully treated with transarterial embolization through the ADS. We reviewed related published articles to determine the safety of embolization via the ADS.

12.
J Neurosurg Case Lessons ; 1(17): CASE2123, 2021 Apr 26.
Artículo en Inglés | MEDLINE | ID: mdl-35855220

RESUMEN

BACKGROUND: This report describes an ethmoidal dural arteriovenous fistula (DAVF) presenting with the unusual symptom of recurrent epistaxis and successfully treated with selective transarterial embolization through the infraorbital artery (IOA), which is the first time this route was used to the best of the authors' knowledge, and reviews the literature focusing on the anatomical consideration of ethmoidal DAVFs causing epistaxis and its treatment approaches. OBSERVATIONS: A 70-year-old man experienced recurrent intractable epistaxis that bled like a faucet turned on. Cerebral angiography revealed an ethmoidal DAVF supplied by the left anterior ethmoidal artery, both sphenopalatine arteries, both IOAs, and the right angular artery, which drained directly into the frontal cortical veins with a tortuous arterialized ectasia. Microaneurysms around the fistulous location where multiple feeding arteries converge were demonstrated and considered the likely source of the epistaxis. The fistula was completely occluded using transarterial Onyx embolization through the IOA, a branch of the internal maxillary artery. No further epistaxis appeared. LESSONS: Although extremely rare, ethmoidal DAVFs should be included in the differential diagnosis of recurrent epistaxis. Ethmoidal DAVFs with bleeding sources in the ethmoid sinus and nasal cavity may cause epistaxis. It is important to properly diagnose and treat ethmoidal DAVFs presenting with epistaxis on the basis of a comprehensive anatomical understanding of extensive extracranial-extracranial and extracranial-intracranial anastomoses.

13.
J Cerebrovasc Endovasc Neurosurg ; 22(3): 182-189, 2020 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-32971577

RESUMEN

We present the case of a patient who developed compressive radiculopathy that was found to be associated with a spinal extradural arteriovenous fistula. The fistula was successfully obliterated with transarteiral balloon-assisted coiling, after which the patient was symptom-free. Although spinal extradural arteriovenous fistula is rare, this pathology should be considered in the differential diagnosis of spinal radiculopathy or myelopathy. Endovascular treatment appears to have been successful in resolving the symptoms associated with this pathology.

14.
J Cerebrovasc Endovasc Neurosurg ; 22(2): 65-77, 2020 Jun.
Artículo en Inglés | MEDLINE | ID: mdl-32665913

RESUMEN

OBJECTIVE: The aim of this study was to assess the feasibility, safety and efficiency of minipterional craniotomy (MPT) for surgical clipping of anterior circulation aneurysms. METHODS: A retrospective study was conducted to compare the MPT from Jan 2015 to Dec 2018 and conventional pterional craniotomy (CPT) from Jan 2012 to Dec 2013 in unruptured intracranial aneurysms (UIA) and ruptured intracranial aneurysms (RIA). The feasibility and safety of MPT and CPT were assessed by analyzing medical records, radiologic imaging, and clinical outcomes. The efficiency of MPT and CPT were based on a survey research of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. RESULTS: Total 628 patients who underwent 458 MPT (UIA:313, RIA:145) and 170 CPT (UIA: 106, RIA: 64) with anterior circulation aneurysms were included in this study. The baseline characteristics between MPT and CPT had no difference (p>0.05). There was no difference in the incidence of postoperative hemorrhage or ischemic lesions between MPT and CPT (p>0.05). The incidence of surgical wound infection was lower in MPT (0.4%) than CPT (3.5%) (p=0.002). More than 90% of postoperative pain disappeared faster in MPT (14.25±4.83 days) than CPT (27.59±10.35 days), and the feeling of facial asymmetry in surgical side was also lower for MPT (1.7%) than CPT (7.6%) (p<0.001). In the MPT, no patients presented with progress to chronic pain, masticatory disability, discomfort of maximal mouth opening or permanent facial palsy. CONCLUSIONS: We suggest that MPT and CPT had similar clinical outcomes, and MPT showed better functional and cosmetic outcomes than CPT in terms of temporomandibular dysfunction, facial nerve paralysis, and facial asymmetry. Therefore, MPT for surgical clipping of anterior circulation aneurysms can be a compatible technique that satisfies the feasibility, safety and efficiency.

15.
J Korean Neurosurg Soc ; 59(5): 458-65, 2016 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-27651863

RESUMEN

OBJECTIVE: The aim of this study is to analyze the differences in the incidence, predicting factors, and clinical course of chronic subdural hematoma (CSDH) following surgical clipping between unruptured (UIA) and ruptured intracranial aneurysm (RIA). METHODS: We conducted a retrospective analysis of 752 patients (UIA : 368 and RIA : 384) who underwent surgical clipping during 8 years. The incidence and predicting factors of CSDH development in the UIA and RIA were compared according to medical records and radiological data. RESULTS: The incidence of postoperative CSDH was higher in the UIA (10.9%) than in the RIA (3.1%) (p=0.000). In multivariate analysis, a high Hounsfield (HF) unit (blood clots) for subdural fluid collection (SFC), persistence of SFC ≥5 mm and male sex in the UIA and A high HF unit for SFC and SFC ≥5 mm without progression to hydrocephalus in the RIA were identified as the independent predicting factors for CSDH development (p<0.05). CONCLUSION: There were differences in the incidence and predicting factors for CSDH following surgical clipping between UIA and RIA. Blood clots in the subdural space and persistence of SFC ≥5 mm were predicting factors in both UIA and RIA. However, progression to hydrocephalus may have in part contributed to low CSDH development in the RIA. We suggest that cleaning of blood clots in the subdural space and efforts to minimize SFC ≥5 mm at the end of surgery is helpful to prevent CSDH following aneurysmal clipping.

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